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Clover Health PA Green (PPO)

Medicare Advantage Plan for Pennsylvania

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Monthly Cost

$0.00

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderCLOVER HEALTH
Plan IDH5141-28-0
CMS Rating1
Plan TypePPO
Annual Deductible$150.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$6,700 In and Out-of-network $6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$260 for days 1 through 6
$0 for days 7 through 90
Out-of-Network:
25% per stay
Outpatient hospital coverage
In-Network:
$90-350 per visit
Out-of-Network:
35% per visit
Doctor visits
Primary:
In-Network:
$20 per visit
Out-of-Network:
35% per visit
Specialist:
In-Network:
$40 per visit
Out-of-Network:
35% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
35%
Emergency care/Urgent care
Emergency:
$75 per visit (always covered)
Urgent care:
$40 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
$0-50
Out-of-Network:
35%
Lab services:
In-Network:
$10
Out-of-Network:
35%
Diagnostic radiology services (e.g., MRI):
In-Network:
$100-150
Out-of-Network:
35%
Outpatient x-rays:
In-Network:
$30
Out-of-Network:
35%
Mental health services
In-Network:
$260 for days 1 through 6
$0 for days 7 through 90
Out-of-Network:
25% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
35%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
35%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
35%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
35%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$160 for days 21 through 100
Out-of-Network:
35% per stay
Rehabilitation services
Occupational therapy visit:
In-Network:
$40
Out-of-Network:
35%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
35%
Ambulance
In-Network:
$200
Out-of-Network:
$200
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$40
Out-of-Network:
35%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
20% per item
Diabetes supplies:
In-Network:
$0 copay
Out-of-Network:
35% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
35%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
35%

Coverage Area for Clover Health PA Green (PPO)

StatePennsylvania
CountyPhiladelphia

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$5 copayNot offered
Tier 2: Non-Preferred Generic$10 copay$15 copayNot offered
Tier 3: Preferred Brand Name$35 copay$45 copayNot offered
Tier 4: Non-Preferred Brand Name$85 copay$95 copayNot offered
Tier 5: Specialty Tier30% coinsurance30% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$15 copayNot offered
Tier 2: Non-Preferred Generic$30 copay$45 copayNot offered
Tier 3: Preferred Brand Name$105 copay$135 copayNot offered
Tier 4: Non-Preferred Brand Name$255 copay$285 copayNot offered
Tier 5: Specialty Tier30% coinsurance30% coinsuranceNot offered

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physician Finder

Physicians that accept Clover Health PA Green (PPO) for Pennsylvania

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